| NPI | 1922399591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN21399) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 10805) |
| 1223G0001X Dentist, General Practice (Licence: MA DN1856061) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 10805) | |
| Enumeration Date | 2011-04-29 |
| Last Update Date | 2021-01-18 |